Myths and Truths in Hospital Ethics (Shashidhara, 7/1/2020)

Thanks so much to Dr. Shilpa Shashidhara for kicking off our new season of Grand Rounds for 2020-2021! I have heard Dr. Shashidhara speak on these topics many times, and there is still so much to learn. . .so much to consider. As I sit listening to Shilpa, I cannot help but flash back on all the challenging ethical questions we face in medicine-- unrepresented patients, surrogate decision-makers, autonomy, futility, beneficence, literally life and death. This. Is. Really. Hard. Stuff.

For your review (and enjoyment), here is a summary of Dr Shashidhara’s Top 10 Bioethical Myths and Truths:
1. Consent for an unrepresented patient: If a patient is unable to make decisions on their own AND they don’t have a surrogate decision-maker, the ethics team should be formally involved to help facilitate discovery of a decision-maker and if unable to do so, to implement Sutter’s Unrepresented Patient Policy. 

2. Capacity determination: Per California law, a capacity determination is the responsibility of the attending physician. Attendings can consult other services (e.g. psychiatry) for help, but the attending physician makes the ultimate determination. 

3. Designating a decision-maker: Even patients with questionable capacity who cannot comprehend complex medical concepts can demonstrate the ability to designate a surrogate. Consistency is the key!

4. Withholding vs. withdrawing care: Although it may feel different to stop treatments that have already started, it is ethically the same as not starting the treatments at all. Patient’s wishes should be respected. 5. Patients demanding treatment: If treatments are deemed medically non-beneficial, the medical team has no obligation to provide them, even when requested. 

6. Hierarchy of decision-makers: There is NO hierarchy of decision-makers in California. As long as the person is aware of the patient’s wishes and is willing to act according to their best interests, anyone can be an appropriate surrogate. This is different than a legally appointed decision-maker (DPOA) named on an Advanced Directive. 

7. On leaving AMA: Insurance companies may decline to pay for a hospitalization for a patient who leaves AMA. Physicians shouldn’t use this possibility to influence a patient’s actions. 

8. Involuntary Holds: There is technically no such thing as a medical hold in California, but a 1799 Hold gives us 24 hours to re-evaluate the clinical situation and determine next steps for a patient who may not want to stay in the hospital but is not safe to go home. 5150 and 5250 holds are only valid in LPS facilities (which we are not). 

9. Code status during surgery: By default, all patients are “full code” during the perioperative period, but exceptions can be made on a case-by-case basis. Ethics is happy to get involved if a patient really wants to remain DNR during a surgery. 

10. Sensitive Services: When a patient is unable to participate in care, family members do not have the right to know the results of sensitive testing (HIV and drug testing) with exception of the surrogate decision-maker, who may need to be made aware of such results to help facilitate decisions.